Provider Demographics
NPI:1326701590
Name:VASQUEZ, VICTOR ALFONSO
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:ALFONSO
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2185 W COLLEGE AVE APT 3018
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-7027
Mailing Address - Country:US
Mailing Address - Phone:541-212-3628
Mailing Address - Fax:
Practice Address - Street 1:341 W 2ND ST STE 3
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1804
Practice Address - Country:US
Practice Address - Phone:909-515-7995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1041C0700XOtherBRIDGE VISION